Why do you need Gap Cover?

Transcription

1 gap cover

2 Gap Cover At Sanlam we re in the business of planning for tomorrow. Of safeguarding futures. And while we wish we could guarantee you a happy-go-lucky, trouble-free future, unfortunately challenges are bound to come your way. Life s biggest challenges often come in the form of poor health. And while no one can promise you a long, healthy life, we can promise you dependable support. 1

3 Why do you need Gap Cover? You may think that if you re a member of a medical scheme you re fully covered for all in-hospital expenses, but in many instances, you re not. In most cases there s a difference between what a specialist charges in hospital, and what your medical scheme will cover. For example, your medical scheme may pay up to R for a hospital procedure. In reality, these costs could be as high as R and escalate upwards. These shortfalls can be high, especially for major procedures, and you might not have cash available to cover them. That s where Gap Cover comes in. Gap Cover pays for this shortfall so you re not out of pocket and don t suffer financially due to unexpected medical expenses. Gap Cover is typically restricted to procedures that take place in a hospital, but some out-patient services are also covered. 2

4 Which benefits does Gap Cover offer? Please note: Gap Cover is not a medical scheme and the cover is not the same as that of a medical scheme. Therefore, this policy cannot be a substitute for medical scheme membership. Monthly premium R250* (younger than 60 years) R600* (60 years and older) In-Hospital Treatment: 2018 Benefits Tariff shortfalls Co-payments Deductibles Penalty co-payment Sub-limits Additional 500% of scheme rate Unlimited cover for specified procedures Unlimited cover for specified procedures Max R cover per family per year R per event/condition Out-Of-Hospital Treatment: 2018 Benefits Oncology co-payments Oncology sub-limits Out-patient treatment Limited to the statutory maximum of R per insured per annum Limited to the statutory maximum of R per insured per annum Co-payments MRI/CT scans (unlimited) 500% Tariff cover Emergency Casualty Benefit (accidental only) Up to R per event (maximum 1 event per annum) 3 * Premiums are the same for single members and members with dependants. Commission of 20% of premium is payable to the intermediary as and when premiums are paid. No commission payable for 60 years and older members.

5 1 Comprehensive Gap Cover Hospital Cash Benefit (only payable for accidents and premature births 6 weeks or earlier, subject to a maximum of R per beneficiary per annum) Day 1 to 13 R300 pd Day 14 to 20 R600 pd Day 21 to 30 R1 200 pd Premature Birth (More than 6 weeks before due date) R per event Death/Permanent Disability Illness R per member Accidental R per member Medical Scheme Premium Waiver 6 months max R4 400 pm Dental Reconstruction (Trauma & Oncology) Up to R per event/condition 2 The enhanced benefits below are only available to Sanlam Reality members. Comprehensive Gap Cover Hospital Cash Benefit (only payable for accidents and premature births 6 weeks or earlier, subject to a maximum of R per beneficiary per annum) Day 1 to 13 R600 pd Day 14 to 20 R1 200 pd Day 21 to 30 R1 800 pd Road Accident Fund (RAF) claims Provided by our out-sourced service provider. For the complete list of benefits, please refer to the Sanlam Gap Cover insurance policy agreement, Section F, BENEFIT SCHEDULE. 4

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7 Who is eligible for Gap Cover? Gap Cover extends to the principal member, their spouse and all children up to age 27. Families covered on 2 medical aids will be covered by a single Sanlam Gap Cover policy. Special dependants, e.g. parents, who are covered on your medical scheme and are registered on the same medical scheme benefit option. You cannot buy Gap Cover if you are not an active member of a registered medical scheme. 6 6

8 What treatments are not paid for by Gap Cover? Specialised Dentistry, excluding the in-hospital basic dentistry benefits on page 8. Treatment for obesity, including bariatric surgery (stomach stapling). Treatment for cosmetic surgery unless necessitated by a trauma, or as a result of oncology treatment (e.g. breast reconstruction following a mastectomy). Any co-payment that is not a defined rand amount (i.e. it is applied as a percentage). Please note that this excludes the oncology co-payment cover. Claims older than 6 months. For the complete list of exclusions, please refer to the Sanlam Gap Cover insurance policy agreement, Section D POLICY EXCLUSIONS. 7

9 The following in-hospital basic dentistry is covered: Fillings (e.g. young children admitted to a day clinic) Extractions (e.g. young children admitted to a day clinic) Surgical extractions (e.g. impacted wisdom teeth) Root canal treatment Non-elective surgery (e.g. periodontitis) Underwriting The medical questionnaire is part of the application form and will be taken into account for medical underwriting. 8 8

10 Are there any waiting periods? Yes, the following waiting periods apply: A general waiting period of 3 months on all benefits. 12 months for pre-existing conditions for which you received advice or treatment during the 12 months prior to the cover commencing. Glossary Tariff shortfall The difference between the specialist s fee and the medical scheme tariff. Co-payment/Deductible The excess payable upfront to the hospital before treatment or a procedure. Qualifying Dependants Spouse, children and special dependants registered on the principal member s medical scheme. Sanlam Reality Sanlam Reality is the Sanlam Group s Lifestyle, Wellness and Rewards Programme. 9

11 How to claim from Xelus Claims are assessed by Xelus Pty (Ltd) on behalf of the insurer, Centriq. Claims must be submitted within six months of an event. We require the following documents from you to process your claim: - Claims transaction remittance from the medical scheme - Relevant doctors accounts - Hospital account (the first four pages showing admission/discharge times and ICD codes) - Current medical scheme membership certificate (copy of the membership card is not accepted) Claims are processed as and when we receive them and claims are paid out on a daily basis. An and SMS are sent to the member when: - The claim is captured. - Outstanding documentation is requested. - The claim is authorised. Please note that payments will only be made to the principal member. Policy Exclusions In order to ensure the long term sustainability of Sanlam Gap Cover, certain exclusions will apply. The main exclusions are listed below for more detail, please refer to the policy document: Day-to-day claims, unless otherwise specified Claims not approved by, excluded by or paid as an ex-gratia by the medical aid Co-payment/deductible that is not a fixed Rand amount (excluding oncology co-payments) Any penalty co-payment, deductible or limitation applied to the medical aid benefits for non-adherence to rules or authorisation procedures (unless spec ified in these benefits) Specialised dentistry such as implants, crowns, bridges, orthognathic surgery, etc. (does not apply to basic in-hospital dentistry, e.g. wisdom extractions or fillings for young children) Claims that are older than 4 months

12 SPF363 10/ Strand Road, Bellville 7530 PO Box 1, Sanlamhof 7532, South Africa Sanlam Gap Cover is underwritten by Centriq Insurance Company Limited. Administered by Xelus (Pty) Ltd. T E sdgapcover@sanlam.co.za